Ulcerative colitis (UC) is a chronic inflammatory and ulcerative disease arising in the colonic mucosa, characterized most often by bloody diarrhea. Extraintestinal symptoms, particularly arthritis, may occur. Long-term risk of colon cancer is high. Diagnosis is by colonoscopy. Treatment is with 5-aminosalicylic acid, corticosteroids, immunomodulators, biologics, antibiotics, and occasionally surgery.

Pathophysiology

Ulcerative colitis usually begins in the rectum. It may remain localized to the rectum (ulcerative proctitis) or extend proximally, sometimes involving the entire colon. Rarely, it involves most of the large bowel at once.

The inflammation caused by UC affects the mucosa and submucosa, and there is a sharp border between normal and affected tissue. Only in severe disease is the muscularis involved. Early in the disease, the mucous membrane is erythematous, finely granular, and friable, with loss of the normal vascular pattern and often with scattered hemorrhagic areas. Large mucosal ulcers with copious purulent exudate characterize severe disease. Islands of relatively normal or hyperplastic inflammatory mucosa (pseudopolyps) project above areas of ulcerated mucosa. Fistulas and abscesses do not occur.

Toxic colitis

Toxic colitis or fulminant colitis occurs when transmural extension of ulceration results in localized ileus and peritonitis. Within hours to days, the colon loses muscular tone and begins to dilate.

The terms toxic megacolon and toxic dilation are discouraged because the toxic inflammatory state and its complications can occur without frank megacolon (defined as transverse colon > 6 cm diameter during an exacerbation).

Toxic colitis is a medical emergency that usually occurs spontaneously in the course of very severe colitis but is sometimes precipitated by opioid or anticholinergic antidiarrheal drugs. Colonic perforation may occur, which increases mortality significantly.

Symptoms and Signs

Bloody diarrhea of varied intensity and duration is interspersed with asymptomatic intervals. Usually an attack begins insidiously, with increased urgency to defecate, mild lower abdominal cramps, and blood and mucus in the stools. Some cases develop after an infection (eg, amebiasis, bacillary dysentery).

When ulceration is confined to the rectosigmoid, the stool may be normal or hard and dry, but rectal discharges of mucus loaded with RBCs and WBCs accompany or occur between bowel movements. Systemic symptoms are absent or mild. If ulceration extends proximally, stools become looser and the patient may have > 10 bowel movements per day, often with severe cramps and distressing rectal tenesmus, without respite at night. The stools may be watery or contain mucus and frequently consist almost entirely of blood and pus.

Systemic symptoms and signs, more common with extensive UC, include malaise, fever, anemia, anorexia, and weight loss. Extraintestinal manifestations of IBD (particularly joint and skin complications) are most common when systemic symptoms are present.

Diagnosis

Stool cultures and microscopy (to exclude infectious causes)

Sigmoidoscopy with biopsy

Initial presentation

Diagnosis is suggested by typical symptoms and signs, particularly when accompanied by extraintestinal manifestations or a history of previous similar attacks. Ulcerative colitis should be distinguished from Crohn disease (see Table: Differentiating Crohn Disease and Ulcerative Colitis) but more importantly from other causes of acute colitis (eg, infection; in elderly patients, ischemia).

In all patients, stool cultures for enteric pathogens should be done, and
Entamoeba histolytica should be excluded by examination of fresh stool specimens. When amebiasis is suspected because of epidemiologic or travel history, serologic titers and biopsies should be done. History of prior antibiotic use or recent hospitalization should prompt stool assay for
Clostridium difficile toxin. Patients at risk should be tested for HIV, gonorrhea, herpesvirus, chlamydia, and amebiasis. Opportunistic infections (eg, cytomegalovirus,
Mycobacterium avium-intracellulare) or Kaposi sarcoma must also be considered in immunosuppressed patients. In women using oral contraceptives, contraceptive-induced colitis is possible; it usually resolves spontaneously after hormone therapy is stopped.

Sigmoidoscopy should be done; it allows visual confirmation of colitis and permits direct sampling of stool or mucus for culture and microscopic evaluation, as well as biopsy of affected areas. Although visual inspection and biopsies may be nondiagnostic, because there is much overlap in appearance among different types of colitis, acute, self-limited, infectious colitis can usually be distinguished histologically from chronic idiopathic UC or Crohn colitis. Severe perianal disease, rectal sparing, absence of bleeding, and asymmetric or segmental involvement of the colon indicate Crohn disease rather than UC. Colonoscopy is usually unnecessary initially but should be done electively if inflammation has extended proximal to the reach of the sigmoidoscope.

X-rays are not diagnostic but occasionally show abnormalities. Plain x-rays of the abdomen may show mucosal edema, loss of haustration, and absence of formed stool in the diseased bowel. Barium enema shows similar changes, albeit more clearly, and may also show ulcerations, but the enema should not be done during an acute presentation. A shortened, rigid colon with an atrophic or pseudopolypoid mucosa is often seen after several years of illness. X-ray findings of thumbprinting and segmental distribution are more suggestive of intestinal ischemia or possibly Crohn colitis rather than of UC.

Recurrent symptoms

Patients with known disease and a recurrence of typical symptoms should be examined, but extensive testing is not always required. Depending on duration and severity of symptoms, sigmoidoscopy or colonoscopy may be done and a CBC obtained. Cultures, ova and parasite examination, and
C. difficile toxin assay should be done when there are atypical features to the relapse or when there is an exacerbation after prolonged remission, during a contagious outbreak, after antibiotic exposure, or whenever the clinician is suspicious.

Acute severe attacks

Patients require prompt hospitalization during severe flare-ups. Flat and upright abdominal x-rays should be taken; they may show megacolon or intraluminal gas accumulated over a long, continuous, paralyzed segment of colon—a result of lost muscle tone. Colonoscopy and barium enema should be avoided because of the risk of perforation, but a careful sigmoidoscopy is typically advisable to assess severity and rule out infection. CBC, platelet count, ESR, C-reactive protein, electrolytes, and albumin should be obtained; PT, PTT, and blood type and cross-match are also indicated in cases of severe bleeding.

The patient must be watched closely for progressive peritonitis or perforation. Percussion over the liver is important because loss of hepatic dullness may be the first clinical sign of free perforation, especially in a patient whose peritoneal signs are suppressed by high-dose corticosteroids. Abdominal x-rays are taken every 1 or 2 days to follow the course of colonic distention and to detect free or intramural air; CT is more sensitive in detecting extraluminal air or pericolic abscess.

Prognosis

Usually, UC is chronic with repeated exacerbations and remissions. In about 10% of patients, an initial attack becomes fulminant with massive hemorrhage, perforation, or sepsis and toxemia. Complete recovery after a single attack occurs in another 10%.

Patients with localized ulcerative proctitis have the best prognosis. Severe systemic manifestations, toxic complications, and malignant degeneration are unlikely, and late extension of the disease occurs in only about 20 to 30%. Surgery is rarely required, and life expectancy is normal. The symptoms, however, may prove stubborn and refractory. Moreover, because extensive UC may begin in the rectum and spread proximally, proctitis should not be considered localized until it has been observed for ≥ 6 mo. Localized disease that later extends is often more severe and more refractory to therapy.

Colon cancer

The risk of colon cancer is proportional to the duration of disease and amount of colon affected but not necessarily to the clinical severity of the attacks. Some studies suggest that sustained microscopic inflammation is a risk factor, and that use of 5-ASA to control inflammation is protective.

Cancer begins to appear by 7 yr from onset of illness in patients with extensive colitis and then develops in about 0.5 to 1% of patients each year thereafter. Thus, after 20 yr of disease, about 7% to 10% of patients will have developed cancer, and about 30% after 35 yr of disease. However, patients who have inflammatory bowel disease and primary sclerosing cholangitis are at a higher risk of cancer from the time of colitis diagnosis.

Regular colonoscopic surveillance, preferably during remission, is advised for patients with disease duration > 8 to 10 yr (except for those with isolated proctitis) or when there is concomitant primary sclerosing cholangitis, in which case surveillance colonoscopy should begin at the time of diagnosis. The most recent guidelines suggest doing
random biopsies (taken every 10 cm throughout the colon) when using high-definition white-light colonoscopy but doing only
targeted biopsies of visible lesions when using chromoendoscopy to detect dysplasia. Definite dysplasia of any grade within an area affected by colitis is liable to progress to more advanced neoplasia and even cancer. After complete removal of endoscopically resectable polypoid or nonpolypoid dysplastic lesions, colonoscopic surveillance is suggested rather than colectomy. Patients with dysplasia that is
not visible endoscopically should probably be referred to a gastroenterologist with expertise in IBD surveillance using chromoendoscopy and/or high-definition colonoscopy to decide whether colectomy or continued colonoscopic surveillance should be done.

The optimal frequency of colonoscopic surveillance has not been established, but some authorities recommend every 2 yr during the 2nd decade of disease and annually thereafter.

Long-term survival after diagnosis of colitis-related cancer is about 50%, a figure comparable to that for colorectal cancer in the general population.

General management

Avoiding raw fruits and vegetables limits trauma to the inflamed colonic mucosa and may lessen symptoms. A milk-free diet may help but need not be continued if no benefit is noted. Loperamide 2 mg po bid to qid is indicated for relatively mild diarrhea; higher oral doses (4 mg in the morning and 2 mg after each bowel movement) may be required for more intense diarrhea. Antidiarrheal drugs must be used with extreme caution in severe cases because they may precipitate toxic dilation. All patients with inflammatory bowel disease should be advised to take appropriate amounts of calcium and vitamin D.

Mild left-sided disease

Patients with proctitis, or colitis that does not extend proximally beyond the splenic flexure, are treated with 5-ASA (mesalamine) enemas once/day or bid depending on severity. Suppositories are effective for more distal disease and are usually preferred by patients. Corticosteroid and budesonide enemas are slightly less effective but should be used if 5-ASA is unsuccessful or not tolerated. Once remission is achieved, dosage is slowly tapered to maintenance levels. Oral 5-ASA drugs theoretically have some incremental benefit in lessening the probability of proximal spread of disease.

Moderate or extensive disease

Patients with inflammation proximal to the splenic flexure or left-sided disease unresponsive to topical agents should receive an oral 5-ASA formulation in addition to 5-ASA enemas. High-dose corticosteroids are added for more severe symptoms; after 1 to 2 wk, the daily dose is reduced by about 5 to 10 mg each wk. Immunomodulator therapy with azathioprine or 6-mercaptopurine can be used in patients who are refractory to maximal doses of 5-ASA and would otherwise need long-term corticosteroid therapy. Additionally, infliximab, adalimumab, and golimumab are beneficial in some patients and may be considered for those refractory to immunomodulator (thiopurine failure) or corticosteroid therapy as well as those who are corticosteroid-dependent. Moreover, a combination of immunomodulator and anti-TNF therapy is sometimes helpful. Finally, in some patients who fail to respond to corticosteroids, immunosuppressants, or anti-TNF drugs, a trial of vedolizumab can be considered.

Severe disease

Patients with > 10 bloody bowel movements per day, tachycardia, high fever, or severe abdominal pain require hospitalization to receive high-dose IV corticosteroids. 5-ASA may be continued. IV fluids and blood transfusion are given as needed for dehydration and anemia. The patient must be observed closely for the development of toxic colitis. Parenteral hyperalimentation is sometimes used for nutritional support but is of no value as primary therapy; patients who can tolerate food should eat.

Patients who do not respond within 3 to 7 days should be considered for IV cyclosporine or infliximab or else for surgery. Patients who do respond to a corticosteroid regimen are switched within a week or so to prednisone 60 mg po once/day, which may be gradually reduced at home based on clinical response. Patients who are started on IV cyclosporine and respond to therapy are switched to oral cyclosporine and concomitant azathioprine or 6-mercaptopurine. Oral cyclosporine is continued for about 3 to 4 mo, during which time corticosteroids are tapered and cyclosporine levels are closely monitored. Some clinicians recommend prophylaxis against Pneumocystis jirovecii pneumonia during the interval of overlapping treatment with corticosteroids, cyclosporine, and an antimetabolite.

Fulminant colitis

If fulminant or toxic colitis is suspected, the patient should

Stop all antidiarrheal drugs

Take nothing by mouth and have inserted a long intestinal tube attached to intermittent suction

Having the patient roll over in bed from the supine to prone position every 2 to 3 h may help redistribute colonic gas and prevent progressive distention. Insertion of a soft rectal tube may also be helpful but must be done with extreme caution to avoid bowel perforation. Even if decompression of a dilated colon is achieved, the patient is not out of danger unless the underlying inflammatory process is controlled; otherwise, colectomy will still be necessary.

If intensive medical measures do not produce definite improvement within 24 to 48 h, immediate surgery is required or the patient may die of sepsis caused by bacterial translocation or even perforation.

Maintenance therapy

After effective treatment of a flare-up, corticosteroids are tapered based on clinical response and then stopped because they are ineffective as maintenance. Patients should remain on 5-ASA drugs—oral or rectal, depending on location of disease—indefinitely because stopping maintenance therapy often allows disease relapse. Dosage intervals for rectal preparations may be gradually lengthened to every 2nd or 3rd day. There is ample evidence that combination oral and rectal therapy is significantly more effective than either therapy alone.

Patients who cannot be withdrawn from corticosteroids should be given thiopurines (azathioprine or 6-mercaptopurine), anti-TNF drugs, or a combination. For more refractory cases, the anti-integrin vedolizumab can be used for both UC and Crohn disease. Also, infliximab, adalimumab, or golimumab are becoming more widely accepted as maintenance therapy for UC.

Surgery

Nearly one third of patients with extensive UC ultimately require surgery. Total proctocolectomy is curative: Life expectancy is restored to normal, the disease does not recur (unlike Crohn disease), and the risk of colon cancer is significantly decreased. After total proctocolectomy with ileal pouch-anal anastomosis (IPAA), there remains a small risk of dysplasia or cancer in the rectal cuff anal transition zone and even in the ileal pouch. After proctocolectomy with ileostomy or IPAA, the quality of life is improved; however, new quality-of-life challenges are created.

Emergency colectomy is indicated for massive hemorrhage, fulminating toxic colitis, or perforation. Subtotal colectomy with ileostomy and rectosigmoid closure (Hartmann procedure) or mucous fistula is usually the procedure of choice because most critically ill patients cannot tolerate more extensive surgery. The rectosigmoid stump may be electively removed later or may be used for ileoanal anastomosis with a pouch. The intact rectal stump should not be allowed to remain indefinitely because of the risks of disease activation and malignant transformation.

The elective procedure of choice in patients with normal sphincter function is restorative proctocolectomy with ileoanal anastomosis. This procedure creates a pelvic reservoir or pouch from distal ileum, which is connected to the anus. The intact sphincter allows continence, typically with 4 to 9 bowel movements/day (including 1 or 2 at night).

Pouchitis is an inflammatory reaction occurring after restorative proctocolectomy with IPAA in about 50% of patients. The risk of pouchitis appears to be higher in patients with primary sclerosing cholangitis, in patients with preoperative extraintestinal manifestations, and possibly in patients with high preoperative serologic titers of perinuclear antineutrophilic antibodies and other inflammatory bowel disease biomarkers. Pouchitis is thought to be related to bacterial overgrowth and is treated with antibiotics (eg, quinolones). Probiotics may be protective. Most cases of pouchitis are readily controlled, but 5 to 10% prove refractory to all medical therapy and require conversion to a conventional (Brooke) ileostomy. For a minority of patients who are older, who have well-established families and lifestyles, who have poor sphincter tone or cannot tolerate frequent bowel movements, or who are simply unable or unwilling to face the consequences of frequent or chronic pouchitis, the Brooke ileostomy remains the procedure of choice.

In any event, the physical and emotional burdens imposed by any form of colon resection must be recognized, and care should be taken to see that the patient receives all the instructions and all the medical and psychologic support that is necessary before and after surgery.

Key Points

UC begins in the rectum and may extend proximally in a contiguous fashion without intervening patches of normal bowel.

Symptoms are intermittent episodes of abdominal cramping and bloody diarrhea.

Complications include fulminant colitis, which may lead to perforation; long-term, the risk of colon cancer is increased.

Treat mild to moderate disease with 5-ASA per rectum and, for proximal disease, by mouth.

Treat extensive disease with high-dose corticosteroids or immunomodulator therapy with azathioprine or 6-mercaptopurine.

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